I am a family physician practicing in Toronto, Ontario. I will be implementing an Electronic Medical Record in my practice, starting in March 2006. This blog is a diary of what happened.

Friday, September 22, 2006

Electronic lab requisitions

I've started using electronic lab requisitions, and electronic Diagnostic Imaging requisitions. The lab reqs replicate the look of the paper Ontario lab requisitions, but the patient information is pre-filled. I had to think about that one, because if that's all there was, there is really no advantage to having electronic lab reqs; in fact, it is faster to just pick a blank req from my pile, tick off the couple of lab tests that I want, and have my secretary put on a label.

However, I found that I could pre-fill a series of lab tests, giving me a list of "favourite" lab forms. I made a series of them: full check up for diabetics, full check up for hypertensives, full check up for people age 40 and over, Methotrexate blood work, first prenatal exam. That is akin to standing orders, and will save me time; it will also increase quality, because now I can't forget to do a microalb/creat ratio for diabetics. I can add additional tests to each req if needed, but I have all the basics covered.

If I generate a lab req electronically, there is a record of what I ordered in the patient encounter; when the results come in, they match against the requisition, so I can see if they were received. However, the match is against the entire req; that is, individual results do not reconcile (the system can't see if the TSH I ordered was done, but it does see whether a batch of lab tests for that requisition came in). That probably stems from the fact that the req is a replica of a paper-based process; individual tests are not coded electronically.

All public health forms (such as HIV or viral studies) are paper-based, and require their own paper requisitions. I have stamped the forms and scanned them in to my system to be printed as needed. All public health results come in on paper only and have to be scanned in. I know public health is very underfunded, but it seems to me that this is one area that would really benefit from better information systems, especially if we have another crisis.

I have a couple of favourite DI reqs, such as bone density requisitions for my hospital, and CXR for the local facility. Saving time in EMRs often comes from automating things that are done repeatedly.

It is interesting being connected. Last week, a patient came in because of a delay: she likely has severe OA of her knee, and she's in her early 50s. The surgeon won't see her until she has a MRI; however, there is a long waiting list for MRIs at my hospital because of high demand. Her MRI isn't until late November, so her ortho appointment was delayed until January; she's in pain. I loaded up the Ontario wait time website, which I've put on my EMR's list of internal websites, and we found a nearby facility with a median wait of only 12 days. I asked my patient to call them, and find out how to refer; a referral sheet came the next day and we faxed it over.

Eventually, I would prefer to send everything electronically (lab reqs, DI, prescriptions, public health, referrals), much like I do my banking. We're still a long way from this.

The blank electronic lab requisitions look like the paper-based Ontario lab requisitions, http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/1000/bul1009_att2.pdf. These were programmed into my system by the software company.